Patient Positioning

The patient is placed on the operating room table in the supine position, and after satisfactory induction of anesthesia, the operative and nonoperative lower extremities are carefully examined. A tourniquet is applied to the upper thigh of the operative extremity and that extremity is prepped and draped in a sterile fashion. When allograft tissue is used, it is prepared prior to bringing the patient into the operating room. Autograft tissue is harvested prior to beginning the arthroscopic portion of the procedure.
The arthroscopic instruments are inserted with the inflow through the superolateral patellar portal. Instrumentation and visualization is achieved through inferomedial and inferolateral patellar portals and can be interchanged as necessary. Exploration of the joint consists of evaluation of the patellofemoral joint, the medial and lateral compartments, medial and lateral menisci, and the intercondylar notch.
When there is a posterior cruciate ligament tear, the tear of the PCL is identified and the intact anterior cruciate ligament is confirmed. The residual stump of the posterior cruciate ligament is debrided with the synovial shaver and hand tools as necessary. In the case of a combined ACL/PCL injury, the residual stumps of both the anterior and posterior cruciate ligaments are debrided. Patients with combined ACL/PCL injuries, the notchplasty for the ACL portion of the procedure is performed at this time.

Initial Incision

An extracapsular posteromedial safety incision is made by creating an incision approximately 1.5 to 2cm long starting at the posteromedial border of the tibia at the level of the joint line and extending distally (Figure 1). Dissection is carried down to the crural fascia which is incised longitudinally. Care is taken to protect the neurovascular structures. An interval is developed between the medial head of the gastrocnemius muscle and the capsule of the knee joint anteriorly. The surgeon’s gloved finger is able to have the neurovascular structures posterior to the finger and the capsule anterior to the finger. This is so that the surgeon can monitor tools such as the over-the-top PCL tools and the PCL/ACL drill guide as it is positioned in the posterior aspect of the knee. This also allows for accurate placement of the guide wire both in a mediolateral and a proximal distal direction.

Elevating the Capsule

The curved over-the-top PCL instruments are used to sequentially lyse adhesions in the posterior aspect of the knee and elevate the capsule from the tibial ridge posteriorly. This will allow placement of the guide and correct placement of the tibial tunnel (Figure 2).

Positioning of the Guide

The arm of the PCL/ACL guide is inserted through the inferomedial patellar portal. The tip of the guide is positioned at the inferolateral aspect of the PCL anatomic insertion site. This is below the tibial ridge posteriorly and in the lateral aspect of the PCL anatomic insertion site. The bullet portion of the guide contacts the anteromedial surface of the proximal tibia at a point midway between the posteromedial border of the tibia and the tibial crest anteriorly approximately 1cm below the tibial tubercle (Figure 3). This will provide an angle of graft orientation such that the graft will turn two very smooth 45˚ angles on the posterior aspect of the tibia and will not have an acute 90˚ angle turn which may cause pressure necrosis of the graft (Figure 4). The tip of the guide, in the posterior aspect of the tibia is confirmed with the surgeon’s finger through the extracapsular posteromedial safety incision. Intraoperative AP and lateral X-ray may also be used. When the PCL/ACL guide is positioned in the desired area, a blunt spade-tipped guide wire (909640) is drilled from anterior to posterior. The arthroscope, in the posteromedial portal, visualizes the tip of the guide wire. The surgeon’s finger confirms the position of the guide wire through the posteromedial safety incision. This is a double safety check.

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Drilling the Tibial Tunnel

The appropriately sized standard cannulated reamer is used to create the tibial tunnel. The curved PCL closed curette is positioned to cup the tip of the guide wire. The arthroscope, positioned in the posteromedial portal, visualizes the guide wire being cupped which protects the neurovascular structures (Figure 5). The surgeon’s finger through the extracapsular posteromedial incision is monitoring the position of the guide wire.
The drill is advanced until it comes to the posterior cortex of the tibia. The chuck is disengaged from the drill, and completion of the tibial tunnel is performed by hand (Figure 6). This gives an additional margin of safety for completion of the tibial tunnel. The tunnel edges are then chamfered and rasped with the PCL/ACL system rasp (Figure 7).

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Drilling the Femoral Tunnel

The PCL/ACL drill guide is positioned to create the femoral tunnel. The arm of the guide is introduced through the inferomedial patellar portal and is positioned such that the guide wire will exit through the center of the stump of the anterolateral bundle of the posterior cruciate ligament (Figure 8). The blunt spade-tipped guide wire (909640) is drilled through the guide, and just as it begins to emerge through the center of the stump of the PCL anterolateral bundle, the drill guide is disengaged. The accuracy of the placement of the wire is confirmed arthroscopically with probing and visualization. Care must be taken to ensure the patellofemoral joint has not been violated by arthroscopically examining the patellofemoral joint prior to drilling. The appropriately sized standard cannulated reamer is used to create the femoral tunnel. A curette is used to cap the tip of the guide wire so there is no inadvertent advancement of the guide wire which may damage the anterior cruciate ligament or articualr surface. As the reamer is about to penetrate interiorly, the reamer is disengaged from the drill and the final reaming is completed by hand (Figure 9). This adds an additional margin of safety. The reaming debris is evacuated with a synovial shaver to minimize fat pad inflammatory response with subsequent risk of arthrofibrosis. The tunnel edges are chamfered and rasped.

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Tunnel Preparation and Graft Passage

A Fanelli Magellan (909808) is introduced through the tibial tunnel into the joint (Figure 10) and retrieved through the femoral tunnel (Figure 11). The tunnel edges are chamfered and rasped with the knee at 90˚, 60˚, 30˚ and full extension. Care is taken to avoid excessive rasp pressure which would alter tunnel configuration.
The traction sutures of the graft material are attached to the loop of the flexible rasp and the graft is pulled into position. The graft material is secured on the femoral or tibial side using the appropriate fixation technique.
At this juncture, if there is also an ACL reconstruction to be performed, the anterior cruciate ligament reconstruction is performed in the conventional manner by drilling the tibial tunnel with the PCL/ACL drill guide, and performing the conventional endoscopic anterior cruciate ligament technique. The ACL graft is passed and secured on the femoral side and left free on the tibial side.

Fixation of the Graft

When the patient also has a posterolateral instability needing reconstruction, it is performed at this time in the surgical procedure. When the posterolateral reconstruction is completed, attention is then turned back to the anterior aspect of the knee for tensioning of the posterior cruciate ligament graft. Traction is placed on the PCL graft sutures and tension is applied. The knee is then cycled through 25 full flexion and extension cycles to allow settling of the graft (Figure 12). The knee is returned to 70˚ of flexion. An anterior drawer force is applied to restore the normal tibial stepoffs and traction is placed on the PCL graft traction sutures. Next, an appropriately sized resorbable interference screw over a guide wire is used to secure the PCL graft . The residual tail of the graft is secured using the No Profile™ Screw and Washer (Figure 13). This provides very secure fixation for the posterior cruciate ligament reconstruction.

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Completion of the Procedure

When a concomitant posterolateral reconstruction has been performed, after the tension in the posterior cruciate ligament has been set, the tension in the posterolateral reconstruction is then set.
In the cases of combined anterior and posterior cruciate ligament reconstructions, the anterior cruciate ligament graft is secured in the conventional fashion after the PCL has been secured.
The tourniquet is deflated. The wounds are copiously irrigated, and the incisions are closed in the usual fashion.